DIVISION OF CORPORATIONS Credit Card/Debit Card …

1 Daytime telephone number:Fax number: Credit card Number:NYS Department of StateDIVISION OF CORPORATIONSC redit Card/Debit card AuthorizationOne Commerce Plaza, 99 Washington , NY this form to your document or written Name of Corporation or Other Business Entity To Which This Service Request Applies is:Check Box for Requested Service:Fill in Fee or Amount:(Consult appropriate fee schedule for filing fees) Routine Service (No Charge), OR Expedited Service: (The fee for each certified copy is $10.)(The fee for each plain copy is $5.)(Certificates of Good Standing, etc. The fee for each certificate is $25.)(Must be served in person at the above address) Account Name: Account Number: TOTAL (Total Amount Due):*Same day expedited service requests must be received by 12 noon.**2-hour expedited service requests must be received by 2:30 service fees are non-refundable and will not be refunded if a filing is Date (Month and Year): Name as it Appears on Credit card or debit card (Print):Cardholder s Billing Address (As listed with Credit card or debit card Company):City:State:Zip Code+4:Cardholder s Signature:Date:If the name on the Credit card or debit card is in the name of a corporation or other business entity, please print the signer s name: DOS-1515-f-l (Rev.)

2 05/13)$$$$$$$$$$$$$ Credit / debit card Information:24-Hour-$25*Same-Day-$75**2- Hour-$150 MasterCardVisaAmerican ExpressFILING OF DOCUMENTS AND CERTIFICATESCERTIFIED COPYPLAIN COPYCERTIFICATE UNDER SEALSERVICE OF PROCESSBIENNIAL / FIVE YEAR STATEMENTOTHERDEPOSIT TO DRAWDOWN(Clears all text entry fields)Routine Service (No Charge), OR Expedited Service: 24-Hour-$25*Same-Day-$75**2-Hour-$150 Routine Service (No Charge), OR Expedited Service: 24-Hour-$25*Same-Day-$75**2-Hour-$150 Routine Service (No Charge), OR Expedited Service: 24-Hour-$25*Same-Day-$75**2-Hour-$150